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    Paediatrics and maternity proctored exam (examplify)

    A client has been in the second stage of labor for 4 hours, they are tired and unsure if they can keep pushing. The fetal head is at +4 station and the fetal heart rate is 110bpm with recurrent late decelerations. The physician advises the client that forceps should be used to help deliver the fetus. Which of the following actions should the nurse perform?

    Explanation & Rationale

    Rationale: A. Monitoring the fetal heart rate is important but does not replace obtaining informed consent. B. Obtaining signed consent ensures the client understands the risks and benefits of forceps delivery and legally authorizes the procedure. C. Advising the client to refuse is inappropriate; the nurse should support informed decision-making, not direct refusal. D. The client will still need to actively participate in pushing during a forceps delivery; advising to nap is incorrect.

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